24327 ArY'LlUAN I I O FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
, Building Project Idemiflodon - PERMIT NO.
Building I 24327
Stas
one:
err a N.Ve,
.)tr e ( - CITY OF CUPERTINOLBUILDING DIVISION
centra ar'sName: LIc.Na: APPLICATION if PERMIT L
!� ? 000 BUILDINC-ELECTRICALPLUMBINGME MCAL CATEGORY CONTROL#
< Itet/Englteer. Lie.Na
n QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: v 0,(" PFRhITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am licensed under provuuneof Chapmr9(commmc APPLIANCFSRESIDENTIAL JOB DESCRIPTION
Ingwe is intton7Wm and effect. lheguclneuandPro/eealonsC-ode,and my —^�
license Ie in tun form and visit. PANELS `G/A9/
License Clam LIc.N
Date Cmmatar UP TO 2DO AhU
I ARCHITECTS DECLARATION 701-1000 AMPS
[Q�ceO ZZ I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E (s Licensed professional SIGNS ELECTRICAL I w,
«<<6tlr'71 OWNER-BUILDER DECLARATION `," l'✓ ,V
O SPECULCR(CI11T/MIST I -
I„ Ihereeyafind leatlamexem)p fromlhe Contranor'c License Lawfmthe
7.o following ichreq(imap7 tto ualnesaand Pmpm neeml:Any tltyir
O Z�� TEMP.METER OR POLE INST. i / �,+-
�, or
cauntywMchprior tesa psicanco also
Maltrequires
theapmv of fees such
I.
nystroture prior to lb huacee,alm requlreelheeppuontfmsuch penNt to POWER DEVICES
-file a signed statement that he h licensed pursuant to the provisions of the
3ro� Contractor's Liceme Law(Chapter 9(commencing with Section 7000)of Divi. SWIM INGIY)OL ELECTRIC eNAI E VyMrATION
stoo3 of the Business and ProfembroCocie)or that he is..mpt therefmmand ^
9ypL'+ a the bash for the alleged exemption. Any violation of Section 702115 by any OU7LE.ISSWLfCI7GSFIXTUR
applicant for a permit subjects the applicant to a civil penalty of not more than tee../ ►'�
ofive hundred dollars MM.
I,as owner of the roc oremployees with we es as their sole NEW RESIDENTIAL ELEC7R SQ.FT STORIES TYPECONSTRUCTION
compen�n ❑ property,nthe i Ya r^Y e
Czq offered for
.1.6rsaction,BuldessandkaProdmodon,nd the ode; h.Is Committees intendedo Lame,Law
F� does e em pplytuan ow er fprop mu Cob:TM1simproveLicense law
whorl [apply tock owner ofp rough who own uilds employees,
imprwnted thaton,such —and OCC.GROUP RES.UNITS
CC.. wprovemuch workhlmselmthmughedhis owne.If,hon,prthebilding or
Improvements arcnotintended earofco plor tale.IL mvnes,g deer ilt have TOTAL:
improvement hsoldwthin he did etbuildorI rythee for Puposerwillhave
tl1 1 L as of pmWf the p he myna build orlmp contra ting with(cense QTY. PLUMBING PERMIT FEC FLOOD ZONE APN
(n I,as owner of the Property,am exclusively Business
and fessions
licensed pp(MITISSUANCE
roeContrsctto mnsladthe project(Sec'0pl to
and of proem Code:
The Coor(roars .tLicenee Lw rices not apply tct,f owner of property who
coeds or Improve themed,and who mntnts for such w. with a ALM -WATER
mp(latorts)licensed pursuant ro the Contractor's License Law. FEE SUMMARY
Lf I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDEFEES
Owner Date DRAINSFLDORROOF,ARE&COND. SANITARY RETE N
WORKMAN COMPENSATION DECLARATION .N��.�P SCHOOL TAX Y_ N_
E31 hereby affirm that I have a certificate of consent to eel-"am,ora RECEIPT Y
milexte of WorkersCompensation lauranmar a cenifted copy thereof(See. GAEA. PARK FEE Y N
1W,lab C.) S RECEIPT'N
Polley Y GAS FA.SYSITb1-0VER d(EA) BUILDING DIVISION FEES
Policy N
1 �Cedifed copy b hereby fumhhed. GREASE/INDU5IAL WASTE INTERCEPTOR PLANCHECKFEE
Cedi ied copy Is filed with the city inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KCRS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Fr Date Recei tit
(Thlssetlon need not be completed if the permit h forme hundred dollars —
($100)arlca.) WATER HEATER W/VENT/ELECTR ENERGYFEE ' Y_ N_
I coney that In the performanceaf the work forwhlch this permit i.heed,
I shall not employ any person in any manner so as to become abject to the WATER SYSTEM/TREATING
Workers Compensation Lawsof Callfomia.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t)Y
Z NOTICE TO APPLICANT:If,after making this Cenulate of Exemption,you
should become subject to the Workers'Compeaation provisions of the Labor TOTAL:
/n Code,you must forthwith comply with such provisions or this permit shall be 1 rt
W NG
] deemed revoked. BUILD -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d 0 I hereby affirm that there Is a construction lending agency for the perform- O AL: ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O Le.der'.Neme PLUMBING FEE
1L F Lender9Address QTY. MECHANICAL PERMIT ITE MECHANICALFEE
OW 1certeylhat]have read thisappBattonand inatelhatlheabove Information
S hooded.I agree to cmddywilh all city and county ordinance and pate laws PERMIT ISSUANCE FEES PAID:
> W relating to building construction,and herebyauthmfrerepresentativesofthis
(_ Z dry to enter upon the above-mentioned pro,"for Wpectlenpurpmes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recti til
V against liabilities,Jsdgmenb,copsand expenses which may In anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalat Id Cky In cons (theg y11tn/en/(��A�ls permit.
AIR HANDLING UNIT ER(OV10,l1fI0CFM) CONSTRUCTION TAX
Slg®tore of App ctor a%l��J�� Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reaef tB
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Heaehand Safety Cade Semon 2553z(a)7 HEATING UNIT(OVER 100,0D0 BTU) TOTAL: , O0
n Yea Na
IILlheappllonl or(umre buildingompantuu aqulpmentmdevim VENTILATION FAN 67NGLE RESIDI ISSUANCE DATE
whichemit ha..dousair contaminantsasciefined by the Bay Area Air BR��C pp
•ality Management District?
BOILER-COMP pFIP OR 100,000 BTU) B' p9 t
Yea No
ave read the haze ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,D00BTU) (j1 1992
(�Q
the California Health&Safety Code,Sections 89 505,25533 and 25534. 1
understand that lithe bu(Idingdoes not currently have a tenant,that It is my NEWRESIDEN7IALMECH. SQ.Fr OCTv
respmuibllity to notify the rampant of the requirements which moat be rant -
priortohuanreofaCeniflcateofOccupancy. CITY OF 1,UNt�
Owneror,authorised agent - Date ISSUEDB
TOTAL:
OFFICE COPY